AUTHORIZATION TO DISPENSE MEDICATION

AUTHORIZATION TO DISPENSE MEDICATION

This form must be completed in its entirety before SoulShine can dispense any medication.
CHILD'S FULL NAME

First NameLast Name
NAME OF MEDICATION
PRESCRIPTIONS NUMBER:
TIME MEDICATION IS TO BE GIVEN
(Medication will not be given on an “As Needed” basis, specifics must be provided)
AMOUNT OF MEDICATION TO BE GIVEN
DATES TO BE GIVEN
(Not to exceed two weeks without a physician’s statement)
PRINTED PARENT/GUARDIAN NAME
PARENT/GUARDIAN SIGNATURE

Clear
TODAY'S DATE

MonthDayYear
Date
FOR SOULSHINE USE (document the reasons why medications are not given as parents requested i.e., child absent, medication not sent, child sleeping etc…)

1.Date   Time given   Amount given   Any reactions   Administered by
2.Date   Time given   Amount given   Any reactions   Administered by
3.Date   Time given   Amount given   Any reactions   Administered by
4.Date Time givenAmount givenAny reactions
Administered by
5.Date Time givenAmount givenAny reactions
Administered by
Should be Empty: